Source · Prevention of Future Deaths

David Celino

Ref: 2023-0303 Date: 21 Aug 2023 Coroner: Kevin McLoughlin Area: West Yorkshire (Eastern) Responses identified: 5 / 5 View PDF

Lack of accurate attendance data for under-18s at festivals, no national oversight of drug casualties, and inadequate staff training for identifying drug reactions contribute to preventable deaths.

Date 21 Aug 2023
56-day deadline 1 Nov 2023 est.
Responses identified 5 of 5
Alcohol, drug and medication related deaths Child Death (from 2015)

Coroner's concerns

AI summary
Lack of accurate attendance data for under-18s at festivals, no national oversight of drug casualties, and inadequate staff training for identifying drug reactions contribute to preventable deaths.
View full coroner's concerns
(1) Neither the organiser of the festival (Festival Republic) nor Leeds City Council which licenced the event had accurate information about the number of people under 18 who were attending the festival. It was estimated to be 20% of the 90,000 attending, so about 18,000. In consequence, the magnitude of the problem of potentially vulnerable, na"ive teenagers exposed to possible exploitation by drug dealers, was not appreciated.

(2) It was said in the course of the evidence that some 4-5 people die annually from illicit drug related causes at the various music festivals held in Britain. It is understood that there is no governing body with oversight of music festivals and hence no record of drug related casualties, which might reveal the extent of the problem.

(3) Without reliable numbers, it is not possible to interrogate the data or establish what proportion of the drug related casualties belong to the under 18 cohort of attendees. National oversight would enable comparisons to be made between different festivals and their respective demographics, as well as providing useful information as to the breadth and depth of the drug problem at different events. This in turn is likely to assist in an assessment of the effectiveness of control measures to prevent (or at least restrict) illegal drugs being brought onto festival sites.

(4) The history of drug related deaths amongst teenagers at the Leeds Festival in recent years has prompted the organiser to explore a greater emphasis on deterrent measures since the 2022 festival. Unless there is a hydra headed campaign to deter illicit drugs being brought onto the festival site, I fear further deaths will occur in circumstances comparable to David Celino's tragic death (whether involving under 18s or other age groups) in Leeds or elsewhere. There is a need to review the way sources of intelligence are harnessed and the enforcement action to be taken against anyone supplying illicit drugs, in order to convey the organiser's determination to create a hostile environment (acting in concert with both its private security personnel and West Yorkshire Police).

(5) Evidence at the inquest indicated David Gelino had walked about the Leeds Festival site between approximately 7pm and 8.45pm on the evening of Saturday 27 August 2022. As the signs of his adverse drug reaction developed, he was unable to walk straight, was pale, sweating profusely and agitated. In the latter stages he needed help from two other 16-year-olds to prevent him falling over. In this period, he passed through at least one check point manned by stewards or security staff. It is likely he encountered other festival staff and/or volunteers in this period also. Lamentably, no staff or volunteers spotted the need to intervene to ask about his well-being or offer assistance. This history suggests further instruction or training for festival staff and volunteers is required as to the need to be proactive, particularly in view of the prevalence of illicit drugs and teenagers. As it was, David Celino's friends only obtained advice as to his condition from the drug dealer they happened to encounter, who reassured them that his reaction as "normal".

(6) Various witnesses raised the issue of "Front of House" drug testing, expressing views as to the benefits and disadvantages of this being permitted. It would help all those involved in the management of events similar to the Leeds Festival to have authoritative guidance on this subject, from the Home Office, along with clarification as to exactly what is permitted.

Responses

5 respondents
Leeds City Council Local Authority / Fire Service
21 Aug 2023 PDF
Action Taken

Leeds City Council, via its Licensing Committee, detailed enhancements made by Festival Republic for the 2023 Leeds Festival, including improved security and stewarding, SIA-accreditation checks on security staff, enhanced staff manuals, daily briefings, and new AIR Hubs. Arrest data analysis suggests Festival Republic's drug security strategy was effective, with increased arrests and drug-related arrests in 2023. (AI summary)

View full response
Response to the Senior Coroner in relation to the Regulation 28 report dated 21 August 2023 Approved by the Licensing Committee on 21 November 2023 Thank you for your Regulation 28 Prevention of Future Deaths report relating to the tragic death of David Joseph Celino. This is a response to the report provided on behalf of Leeds City Council (LCC) through its Licensing Committee. The Matters of Concern raised by the Senior Coroner in the Regulation 28 report have been carefully considered by the Committee, which has approved this response at a meeting on 21 November 2023. All members of the Committee offer their condolences to the family and friends of David Celino. Background LCC is the Licensing Authority for the Leeds Festival under the Licensing Act 2003. Its powers and functions in that capacity are defined by the 2003 Act. LCC’s Licensing Committee granted a premises licence for the Leeds Festival on 28 April 2006. That licence continues to have effect until and unless it is revoked or suspended, surrendered, or lapses due to the death, incapacity, insolvency etc of the holder. Under the terms of the licence, each year before the festival the Licensing Committee considers and approves the licence holders’ Event Management Plan (EMP). Following each year’s festival, the Committee holds a de-brief meeting including consideration of improvements for the following year. The multi-agency Safety Advisory Group (SAG) also provides advice in relation to the event. The SAG is made up of representatives from the local authority, emergency services, and other relevant bodies. They meet to review event applications and advise on public safety. The licence holders and organisers of the Leeds Festival, Festival Republic Ltd, have worked with the Council and other stakeholders, including the Police, over the years to introduce and improve on safety and welfare provision at the event. The Coroner’s Matters of Concern (1) Lack of accurate information about the number of attendees under the age of 18. The Licensing Committee has been mindful of the need for information on the number of under-18 attendees for some time, and has been in discussions with Festival Republic since early-2021 over ways of accurately capturing this data. Festival Republic highlighted the difficulties in capturing this data at the point of sale, given the common occurrence of ticket resale and exchange. Consequently, a system of under-18 wristbands was implemented at the 2021 festival but proved unsuccessful and gave rise to concerns about the safeguarding implications of visibly identifying under-18s. At the Committee’s debrief meeting for the 2022 festival, held in January 2023, Festival Republic Ltd committed to implement a new and more robust system for future events to capture accurate numbers 1

of attendees aged 16 and 17. The Committee’s expectation that this would be delivered for the 2023 festival was confirmed in a letter to Festival Republic Ltd dated 24 January 2023. The system implemented by Festival Republic for the 2023 event was that every attendee was required to show identification documents with proof of age at the point of exchanging their tickets for wristbands. Staff at the wristband exchange counters would then check the ID and keep a count of 16­ and 17-year-olds in attendance, by scanning the appropriate QR code. The data thus obtained captured the numbers of 16/17 year olds, and also differentiated between those who were accompanied by an adult and those unaccompanied. Officers from the Council’s Entertainment Licensing service attended the festival to observe the system in operation, and based on their observations were satisfied that it was implemented successfully. During the festival itself, the numbers were shared with SAG partners at the daily on-site debrief. The data for the entire festival has been provided to the Committee for consideration at the 2023 debrief and will inform the consideration of future Event Management Plans. (2) No national governing body with oversight of music festivals in Britain and no records of drug related casualties at festivals nationally. The Licensing Committee draws upon available specialist expertise from the multi-agency SAG in its consideration of the EMP for the Leeds Festival. The Council agrees that guidance, oversight and data from a national governing body for music festivals would be extremely valuable in this process and would welcome such a body being introduced. The Licensing Committee chair will write to the Secretary of State to support the introduction of such a body. (3) Without reliable numbers it is impossible to establish what proportion of drug-related casualties are under 18; national oversight would enable comparisons between festivals and aid assessment of the effectiveness of anti-drug control measures. At the national level, the Council agrees that national data for drug-related casualties at different festivals would be a useful metric to help assess the effectiveness of anti-drug measures, and would welcome such data being made available. The Chair of the Licensing Committee will endorse this proposal in his letter to the Secretary of State. Specifically in relation to the Leeds Festival, the Licensing Committee has been provided with a report of medical interventions at the 2023 festival which includes number of persons treated, broken down by age. The figures have been provided in Festival Republic’s response to the Senior Coroner’s report and are not repeated here. (4) Need for a hydra headed campaign to deter illicit drugs being brought onto the festival site. The Council can give an overview of steps taken on this issue in its role as Licensing Authority for the festival, but the responses from Festival Republic Ltd and West Yorkshire Police contain greater detail. 2

In advance of the 2023 festival, Festival Republic introduced a new drug security strategy devised by a former police Detective Superintendent, which intended to create a hostile environment for criminals targeting the festival to supply illicit drugs, and to deter the use of illegal drugs by festival goers. The strategy involved enhanced security and searches on the entry gates; high visibility patrols by Security Industry Authority (SIA) accredited security staff; covert security operations within the site; intelligence- led targeted security operations; appropriate response to reports of illegal activity via the security staff and Police; and identification and targeting of organized crime groups on site. Analysis of the arrest data indicates that Festival Republic’s new drug security strategy has been effective. Arrest data in respect of the 2023 festival showed an increase in the number of arrests, up from 50 to 72, in addition to an increase of drugs-related arrests as a percentage of all arrests made, up from 58% to 83%, when compared with data from the 2022 festival. (5) Need for further training and instruction for festival staff and volunteers. Again, the Council can give an overview of the steps taken but Festival Republic can respond in finer detail. For the 2023 event, Festival Republic enhanced the security and wellbeing provision through improved and more visible security and stewarding, particularly in campsites and egress routes; Security Industry Authority (SIA) -accreditation checks on security staff (SIA accredited security staff are trained in welfare, safeguarding and first aid); improved staff manuals; daily briefings for security, staff and volunteers; and the new provision of Assistance, Information and Response (AIR) Hubs placed at strategic points around the campsites and marked with bright LED signage. Officers of the Council’s Entertainment Licensing service witnessed improved proactive security and stewarding during the 2023 festival. (6) Need for authoritative Home Office guidance on Front of House drug testing. The Council recognises that there are complexities around Front of House drug testing, with differing views on its effectiveness as a safety measure, and whether it conflicts with anti-drug policy and messaging. The Council would welcome clear, evidence-based Home Office guidance on this subject.

Chair of the Licensing Committee 3
Festival Republic
21 Aug 2023 PDF
Action Taken

Festival Republic implemented improvements for Leeds Festival 2023, including enhanced security at gates, search operations, presence of dogs, visible messaging, and covert operations. They addressed medical facilities concerns by improving the Forward Operating Base, triage processes, ambulance resourcing, and welfare support. They also plan to consider further improvements for the 2024 festival. (AI summary)

View full response
Dear Mr Mcloughlin, I am writing as requested, in response to the concerns expressed by the Coroner in the Regulation 28 Report dated 21 August 2023. In two witness statements, dated 12 June 2023 and 10 August 2023, I set out many improvements which Festival Republic proposed to implement for Leeds Festival 2023 . In addition, in my evidence at the Inquest, I referred to further measures that would be put in place in 2023 or, where the timescale prevented this, would be carried forward to be implemented at future festivals. I set out below the improvements made for Leeds Festival 2023 and further improvements which will be considered for Leeds Festival 2024 within the planning process for that Festival. Licensing Authority and Safety Advisory Group (SAG) All of our plans which together constitute the Event Management Plan for Leeds Festival 2023, were approved by the Licensing Authority, the Responsible Authorities and SAG prior to the festival commencing in August 2023. Pre-event inspections were carried out by members of the Licensing Committee and Officers of Leeds City Council. Throughout the Festival, SAG meetings were convened daily to share information and where necessary, address issues or concerns that arose . A Multi-Agency debrief took place on 6 October 2023 . The feedback from this debrief was very positive. A number of themed areas were discussed, including 'Policing Issues', 'Security', 'Medical' and 'Safeguarding'. It was noted that the hard line taken this year was welcomed by all. It was agreed that the event was "successful in building a hostile environment for drug dealers at the festival" by the Security at gates, search operations, presence of dogs and visible messaging. In addition, covert operations were in place, including the campsite, which resulted in arrests. The West Yorkshire Police confirmed that there had been 71 arrests, noting most were for the supply of drugs. Prosecutions have taken place which I will refer to later. The police commented that "the increase in robust security and dealing with anti-social behaviour on site with more evictions by FR made the event feel more safer than in previous years." 1

Festival Republic Limited, The Farmiloe Building, 30 St John Street, London, EC1M 4AY

It was agreed that the approach taken in 2023 should be carried forward to the 2024 festival. In addition, the SAG meeting noted improvements in security, medical provision, safeguarding and "saw lots of positives". Planning for Leeds Festival 2024 An internal review by Festival Republic has taken place and the drafting of an Event Improvement Plan for 2024 covering all aspects of the festival has commenced. We are in the process of carrying out debrief meetings with our contractors. The planning process has already begun with debriefs within Festival Republic and debriefs with some Responsible Authorities and Sub Groups, in addition to the Multi Agency debrief described above. A debrief meeting with the Licensing Committee is scheduled for 21 November 2023. Any recommendations for further measures that emerge from this debrief will be included in the planning process for Leeds Festival 2024. Education and Messaging about Drug Awareness In my earlier statements, I explained our use of social media platforms both before and during the Festival, including Facebook, lnstagram and Tik Tok, messaging on our website and messaging on the main stage LED screens between performances throughout the festival. This was fully implemented for the Festival in 2023. In addition, messaging was provided to festival goers via the Leeds Festival App throughout the festival which had 88,000 active users and almost a million user sessions. Varying messages were created and developed in conjunction with FACT (Festival Advice and Campaign Team), including: " There is no safe level of drug use. The safest way is to not to use them at all." "Know your limits. Tolerance levels vary - Don't feel pressured to do anything you don't want to do." "If your mates a state, keep them safe. Stick together. Don't leave anyone behind." Messages were also shown on the big screens during every change over of performers throughout the weekend. A debrief meeting was held on 28 September 2023 with FACT members and the results were shared from a post-festival survey completed by Festival Republic demonstrating that the #LookOutForEachCampaign was seen by 90% of the Leeds Festival audience with many commenting on the positive and appropriate messaging being shared across the site. Examples of this feedback from the audience we received are as follows: "I thought it was excellent! Because of the campaign, people were genuinely looking out for each other. If someone needed to get out the crowd, people were quick to help unlike previous years". "I think it is a very positive message. I am happy that it wasn't every once in a while but rather, it was on many screens, posters and staff promoting it as well as the acts themselves also did so". 2

Festival Republic Limited, The Farmiloe Building, 30 St John Street, London, EC1M 4AY

"I felt it was pushed an appropriate amount without being patronising or losing meaning. The alerts on the app were friendly and helpful too". Posters were also displayed in 2023 highlighting key messages from the #LookOutForEachOther campaign in high footfall areas throughout the Site and this messaging was displayed on the LED screens at the campsite Assistance, Information and Response (AIR} Hubs. The posters were printed on foamex boards and were each 1.8metres in height, by 1.2metres in width (6ft x 4ft). They were displayed on each AIR Hub (x 16 in total), at each Information Point (x 2 in total} and within the arena (a further x 10). In 2023 our messaging was more widely communicated than before, and in addition to the above, broadcasts were made on BBC Radio . The FACT Team will reconvene on 20 February 2024 to review the messaging and discuss further improvements for 2024. In addition, we are currently liaising with the police and focus groups regarding education in schools and colleges with the intent of bringing our messaging and campaigns into these environments. Campsite Welfare At Leeds Festival in 2023, we had 2 fully equipped Welfare Tents serving the campsites which provided additional resources and facilities to the smaller Hubs which had been provided in 2022. Each Welfare Tent was operational 24 hours each day and staffed by a trained welfa re team and supplemented by an HIDC medical technician with the ability to assess, triage and provide life-saving treatment. In addition, the AIR Hubs in the campsite operated 24 hours each day of the festival. The feedback received via the SAG, Safeguarding Sub-Group, and welfare teams on the ground is that these worked well. In total, there were 816 people seen at the Campsite Welfare points. In 2024, we plan to keep the two fully equipped Campsite Welfare tents and look to review the medical presence to offer more than preliminary triage and assistance. This will need further discussion with our welfare and medical providers. Medical Provision As in previous years, in 2023, the Medical Plan was prepared by Senior Emergency Department or Intensive Care Unit Consultants and Tactical and Operational Commanders experienced in working in the NHS and at events on Greenfield sites with experience of accident and emergency conditions and treating illness associated with drugs overdoses. In the Arena we had 3 medical facilities and in addition to this, the main medical centre (a Field Hospital) in the Village/campsite area . The main Medical Centre was well equipped with advance diagnostic equipment available; point of care blood gas testing; saliva drug testing; point of care CRP (blood infection markers); point of care 0-Dimer (blood test); point of care high sensitive Troponin; urinalysis and ultrasound. 3

Festival Republic Limited, The Farmiloe Building, 30 St John Street, London, EC1M 4AY

New for 2023 was an on site x-ray facility which enabled diagnosis on site so that appropriate treatment could be provided on site and referrals to hospital for x-rays and treatments could be reduced to minimise the impact of the event on the wider healthcare system. An exercise was carried out with the Senior medical staff to ensure roles and responsibilities were clear. As before, local hospitals were contacted and emergency numbers and protocols agreed. We also had 7 dedicated ambulances on site operational 24 hours a day. The medical provision for 2023 was discussed and approved by Yorkshire Ambulance Service and NHS England. The main Medical Centre had the ability to manage, and as a priority, stabilise a critically unwell patient prior to transport to hospital, including the ability to deliver an emergency anaesthetic on site, ventilatory support such as CPAP or BIPA. As part of the main medical centre there was an extensive medication stock to appropriately manage and treat patients as required . The Medical staffing on site consisted of: Days 1 X Emergency Department Consultant 1 X Emergency Department Registrar l X General Practitioner 2 X Advanced Care Partitioner l X Radiographer 2 X Emergency Department NMC Registered Nurses 7 X HCPC Registered Paramedics 14 X Ambulance Technicians 15 X Emergency Care Assistants 14 X First Responders Night 1 X Emergency Department Consultant 2 X Emergency Department Registrar 1 X Advanced Care Partitioner 1 X Radiographer 2 X Emergency Department NMC Registered Nurses 5 X HCPC Registered Paramedics 7 X Ambulance Technicians 9 X Emergency Care Assistants 6 X First Responders The medical provision was commended by members of the SAG, and feedback from an assurance visit carried out on the Sunday of the festival observed the operation working well and staff being appropriately engaged. A debrief/planning meeting will take place between my team and the 4

Festival Republic Limited, The Farmiloe Building, 30 St John Street, London, EC1M 4AY

medical providers before the end of the year. It was commented by YAS that the early engagement of a Care Quality Commission (CQC) registered company was welcomed and we plan to take this forward to 2024. Medical data was collected as follows : With regard to the drugs-related cases this year (2023), there were 83 presentations in total, 42% (35) of these were 16/17 yea r olds (22 x 17 year olds, 13 x 16 year olds). In 2022, there were 72 drugs-related presentations in under 18s. The figures show a significant reduction of the presentations in under 18s in 2023 compared to the figures in 2022. For 2024, as mentioned earlier, we will review the medical resource support in the Campsite Welfare Tents. Provision of Voluntary Testing of Drugs On Site At the Festival in 2023, we continued to have a Back of House testing service available, facilitated by West Yorkshire Police, which enabled us to feed harm reduction messaging to festival goers via social media platforms, the Leeds Festival App and the main stage screens. There were no known drugs of a particular high strength in circulation that needed alerting to the audience. In the on-site SAG meeting held on Sunday 27th August it was observed that there had been no concerns regarding the potency of drugs in circulation at the festival and therefore it was not necessary for any tailored public health messaging to be communicated . Front of house testing was not carried out because it is not permitted . Recording Age of Attendees · Prior to the Inquest, I committed to putting in place a system for recording the number of 16 and 17 year olds on site, each day of the Festival in 2023. I was able at very short notice, to put this in place prior to the festival in 2023. We introduced a system for checking and recording these festival goers by requiring all young persons to bring ID with them to show proof of age at the point of exchanging their ticket for a wristband. An electronic system, using scanners and different QR codes was implemented to record this information accurately. This system worked well but can be improved and streamlined. We were able to record the exact number of both accompanied and unaccompanied 16 and 17 year olds entering the site, however we did not then scan persons upon exit. We also collected data about the number of under 18 persons who presented for medical treatment including their conditions. All data was reported to SAG on a daily basis throughout the Festival. The data relating to drugs related cases is shown above. Prior to the Festival in 2023, we increased the number of CCTV monitor observers in Event Control from 3 to 5 at peak times. In addition to their normal duties, we briefed observers to emphasise 5

Festival Republic Limited, The Farmiloe Building, 30 St John Street, London, EC1M 4AY observing for suspected illegal drug issues, including but not limited to, spotting for suspicious activity, drug dealing and persons (especially younger persons) who appeared to be under the influence of drugs. The protocol was for the CCTV monitor observers to report all such activity to Event Control to enable it to action the appropriate response . One observer was tasked with specifically monitoring drug incidents and supporting drugs operations. It was recognised by the Police that this helped to secure more drug arrests in 2023 . The CCTV plan will continue to be under constant review. Additional Briefing for Security and Staff In my statements I set out the proactive surveillance for the wellbeing of festival goers, but during the Inquest, I recognised that this could be improved. Therefore, in addition to the messages in the Staff Handbook and the normal briefings, I put in place for the 2023 Festival, additional briefings for staff and contractors (especially security, stewards and volunteers) that observation of the wellbeing of festival goers was a primary task together with a duty to act where festival goers (and especially young festival goers) seemed unwell. The protocol required, depending upon the condition of the festival goer, that the festival goer should be helped to either a medical or welfare provision as appropriate. Also, new for 2023, on Tuesday 22 August 2023, I sent a Newsletter to all of my staff and all workers on site, prior to opening the Festival reinforcing my message. These measures were in place for the 2023 Festival but I am awa re that it requires a.change in culture . Therefore, I still regard it to be a work in progress and I am committed to promote this culture at Leeds Festival and all of our Festivals in the future. Drugs and Safety Operation For Leeds Festival 2023 I committed, with the full cooperation and support of West Yorkshire Police, that we would provide a "hostile environment" on site for criminals attending the Festival with intent to supply and distribution illegal drugs. The strategy was set out in paragraph 49 -51 of my second statement and in the Campsite Strategy Document dated 26 July 2023 prepared by a former senior officer with West Yorkshire Police. This former West Yorkshire Police Officer was appointed as the Crime Reduction and Police Liaison Officer at the Festival in 2023. The strategy contained 5 limbs :
• The covert response
• Overt patrol and reassurance
• Intelligence led security initiatives
• The response to reported criminal activity
• The response to the presence of Organised Crime Groups 6

Festival Republic Limited, The Farmiloe Building, 30 St John Street, London, EC1M 4AY

All of the 5 limbs of the strategy were fully and successfully implemented during the Festival. Liaison with West Yorkshire Police was improved with a West Yorkshire Police Officer stationed permanently in Event Control. Additional resources were provided, double the number of drugs dogs, additional security, additional Police, additional CCTV operators, specifically to support drugs operations and greater sharing of intelligence. The enforcement process was clearer, with liaison between security and the Police in evidence gathering and handover of suspects. Press reports of the arrests have recounted successful challenges by Security to suspected drug dealers, their apprehension and handover to Police for further action. In 2023 there were 71 arrests made in total, 83% (59) for drugs-related offences (4 for possession, 55 for possession with intent to supply, largely involving semi-organised drug groups from other areas of the country) . In 2022, there were 50 arrests made in total, 58% (29) of these were drugs related. In addition to arrests, so far there have been 4 successful prosecutions of drugs dealers with lengthy custodial sentences being imposed . When passing sentences on two dealers, the Judge publicly warned drug dealers that "others caught selling [drugs] can expect long sentences". This warning was reported in the media . The strategy of creating the hostile environment for drug dealers will be implemented in 2024. Safeguardin_g The Safeguarding Operation Pla n was reviewed and revised in conjunction with our safety partners for the 2023 Festival. It provided a wide ranging review, covering not only safeguarding but also medica l, welfare and security provisions. Our plan provided for an increase in safeguarding management which was more robust over 24/7 throughout the whole Festival. The Plan also identified that specific messaging was required for minors, visits to schools to get basic drug harm advice was recommended, messaging about drug harm should be sent out early, emphasis should be placed on safeguarding minors in possession of drugs and better illumination of signage in the campsite, welfare areas and medical areas was required . All of these recommendations were carried out with school visits undertaken by the Police. Again, for 2024, we are liaising with the Police to get drug awareness messaging into schools and sixth form colleges well in advance of the 2024 Festival. Governing Body with Oversight of Festivals The Report raises, as a matter of concern, that there is no Governing Body with oversight of festivals. The Licensing Regime introduced by the Licensing Act 2003 places the authorisation of festivals and other events with Licensable Activities within the remit of the local Licensing Committees. A Premises Licence is the main authorisation required . It was deliberate to place the responsibility with loca l Licensing Committees because they were considered to be best informed, with the aid of 7

Festival Republic Limited, The Farmiloe Building, 30 St John Street, London, EC1M 4AY

representations from the Responsible Authorities and the advice of SAG, on local matters and issues which might need to be addressed to promote the four Licensing Objectives :
• Prevention of Crime and Disorder
• Public Safety
• Prevention of Public Nuisance
• Protection of Children from Harm Local Authorities, issue Licensing Policy which amongst other things, advises upon issues (including special local issues) that Premises Licence Holders must address to promote the Licensing Objectives. There is also a robust enforcement regime where a Review of a Premises Licence can be called for and the Licensing Committee may impose further conditions or revoke a Licence . Licensing Officers, other Council Officers (for example, concerning safety, environmental health, trading standards etc) and Police Licensing Officers all attend festivals to ensure the relevant laws, regulations and Premises Licence Conditions are being complied with. At Government level, I believe that licensing falls under the remit of the DCMS. In addition to the Licensing Act 2003, there is statutory guidance pursuant to the Act, (Section 182 Guidance), which elaborates on the requirements for the promotion of the four Licensing Objectives. This guidance is updated from time to time. It is also within my knowledge that certain issues, for example security issues, terrorism etc., are addressed in meetings with DCMS Officials, other Government Departments such as the Home Office and industry representatives. I have attended such meetings. In addition, there are number of industry bodies which discuss issues that arise and issue advice . For example, The Purple Guide, which is regularly updated, provides industry guidance for festivals and other events. Best Practice is constantly under review and evolving. I believe that a robust structure is already in place to provide safe festivals, concerts and events which are attended in Great Britain by several million festival goers each year. I struggle to see what further oversight a Governing Body could provide. Collection of National Statistics In my experience, from the festivals; concerts and events that we organise throughout Great Britain each year, data relating to criminal activity, drugs casualties and medical referrals is recorded by us and is presented during post-event debriefs with the Licensing Authorities and Responsible Authorities. This data and experience is then fed into planning for events in future years. Therefore, drug related casualties, their number and trends are all taken into account on a local basis which is in line with the local structure of the Licensing Regime . In the case of Leeds Festival, we have access to data from Reading Festival, which is the most comparable Festival to Leeds Festival, which can be shared with the Leeds Licensing Authority and Responsible Authorities when requested. We also 8

Festival Republic Limited, The Farmiloe Building, 30 St John Street, London, EC1M 4AY

have experience and data from all of our other festivals and events spread across Great Britain to inform us. In addition to this data, our close liaison and intelligent sharing arrangements with West Yorkshire Police (and other police forces) enable us to be warned of current trends in criminality and organised crime so that appropriate operations can be put in place. In the London Metropolitan area, a meeting takes place in Spring each year between the Metropolitan Police Service and event organisers which reviews major events and discusses challenges for the forthcoming year. This intelligence is then fed into the planning for those events. I do not object to supplying data to a National Database (subject to Data Protection Regulations) but doubt that this will assist in fighting drug related casualties at festivals, concerts or other events. I consider the fight against drugs and the peddling of drugs at festivals is best addressed at a local level. Whilst I have reservations about Front of House drug testing, the creation of a Governing Body with oversight of festivals and the collection of National Statistics for Festivals, my mind is not closed and I would be prepared to engage further on these proposals. Finally, as I mention above, the debrief with Leeds Licensing Committee has not yet taken place and should further matters relevant to the concerns expressed in your Report arise from this meeting, I will write to you again to comment upon these.
Festival Republic
9 Nov 2023 PDF
Noted

Festival Republic provides updated arrest statistics from West Yorkshire Police regarding drug offenses at an event. (AI summary)

View full response
Dear Mr McLoughlin RESPONSE TO REGULATION 28 REPORT – 21 AUGUST 2023 Further to response of yesterday, I am writing to you to update the quoted arrest statistics which have been updated to me today by West Yorkshire Police. The statistics in

letter were those provided by West Yorkshire Police at the SAG debrief in October. The up to date statistics are as follows: Total arrests: 72 Total arrests for drug offences: 59. These comprise 4 for possession of drugs offences and 55 for supply of drugs offences. I hope this update is helpful.
West Yorkshire Police Police / Law Enforcement
13 Nov 2023 PDF
Action Taken

West Yorkshire Police increased measures to combat drug supply at the 2023 Leeds Festival, including a dedicated intelligence researcher, liaison with other festivals, robust searches at ingress points, increased use of drug dogs, covert operations, and a WYP officer stationed in the Festival Republic Control Room, resulting in more arrests. They will also ensure a dedicated detective inspector attends the hospital with the ill person in future. (AI summary)

View full response
Dear Mr McLoughlin (HM Senior Coroner),

I write on behalf of the Chief Constable of West Yorkshire Police in response to the Prevent Future Deaths Report dated 21 August 2023. Whilst I will only comment on paragraph 4, I would like to assure you that West Yorkshire Police (WYP) have considered all the issues you have raised and will continue to work closely with Festival Republic and other partners. Following the 2023 festival, WYP have participated in a number of debriefs with Festival Republic and the Safety Advisory Group.

WYP remains committed to targeting those connected with the supply of drugs at the festival. In the months leading up to the 2023 festival, a dedicated intelligence researcher was used to harness intelligence from a number of different sources. To assist in identifying any trends at U.K. festivals that had taken place before the Leeds Festival, WYP liaised with Festival Republic and the National Police Coordination Centre Strategic Intelligence & Briefing (who provide regular information and intelligence updates during the festival season). As Silver Commander for the Leeds Festival, I also liaised with the Silver Commander for the Reading Festival.

I believe that the additional measures (which I have detailed below) did create a more “hostile environment” for drugs supply at the 2023 festival and led to an increase in the number of arrests, in particular of persons who were in possession of a controlled drug with the intent to supply it to another (PWITS). In 2023 there were 72 total arrests at the event, which included 59 arrests for drug related offences – 4 for Possession and 55 for Drugs Supply offences. The Crown Prosecution Service concluded that there was sufficient evidence in 8 cases to charge and remand a person, with 4 of these already having been prosecuted and receiving significant custodial sentences. The remainder are ongoing police investigations with suspects on bail / under investigation that may progress to charges when the investigations are fully complete.

Only 14 of those arrested for drug offences were from the West Yorkshire area; the majority of offenders resided in the Greater Manchester, Merseyside and South Yorkshire area. WYP intends to liaise with these Police Forces in the lead up to the 2024 festival.

As referred to above, a number of additional measures were implemented for the 2023 festival which included:

• Festival Republic conducted more robust searches at ingress points.
• An increased use of drugs dogs and discreet searches on entry by Festival Republic.
• When drugs were located during entry searches, police detectives were present to triage what the police response should be.
• An increased visible police presence at ingress points.

x Festival Republic provided drugs messaging at points of ingress on large digital screens. x Amnesty bins were placed at ingress points. x Covert operations. x For the first time, a WYP officer was stationed directly within the Festival Republic Control Room. x Festival Republic provided additional CCTV operators.

It is important to note that as in previous years, WYP attended daily security briefings where intelligence was shared between WYP and Festival Republic.

These measures ensured that we were able to identify and arrest persons who were supplying drugs. The Crown Prosecution Service decides which cases should be prosecuted and determines the appropriate charges. Where it is appropriate (and in consultation with the Crown Prosecution Service), confiscation or forfeiture orders are sought to deprive the defendant of the proceeds of crime.

After listening to the concerns raised by David’s family, WYP have reflected on how the initial stages of the investigation were dealt with and, in future, would ask another night Duty Detective Inspector to attend the hospital with the person who had become ill, allowing the night Duty Inspector at the festival to focus on the crime scene, potential suspects etc.

Debrief discussions between Festival Republic and WYP have suggested that the measures adopted for the 2023 festival will be replicated for the 2024 festival.

Sincerely,

Neighbourhoods & Partnerships Silver Public Order and Public Safety Commander at leeds Music Festival 2023 Leeds District Police HQ, Elland Rd, Leeds, LS11 8BU West Yorkshire Police
Home Office Central Government
PDF
Noted

The Home Office highlights government efforts to tackle illegal drugs through police action, reducing demand, and improving treatment. It notes that organisations wishing to deliver back-of-house drug checking facilities at festivals can apply for a license. (AI summary)

View full response
Dear Mr MCLoughlin, Thank you for your report under Regulation 28 of the Coroner (Investigations) Regulation 2013, dated 21 August and addressed to the Home Secretary about the death of Mr David Joseph Celino. I am responding as the Minister of State for Crime, Policing and Fire. Any death related to illicit drugs is a tragedy. Drugs have a devastating effect on individuals and their wider communities. The Government is committed to tackling the supply of illegal drugs through relentless police action, reducing the demand for illegal drugs through a zero-tolerance approach and building a world-class system of treatment and recovery to turn people's lives around and prevent crime. In July 2023, the Government published the first annual report on the Drug Strategy. This set out the progress made in the first year of the delivery of the Government's 10-Year Drug Strategy, From Harm to Hope and the Government's priorities going forward. Key achievements in the first year, to March 2023, include:
• Closing over 1,300 county lines, against a three-year ambition to close 2,000 lines, with over 2,000 arrests and 3,200 safeguarding referrals.
• Increasing the drug and alcohol treatment workforce with 1,670 additional staff, including 1,255 drug and alcohol workers, 479 of whom are focused on criminal justice.
• Increasing the number of referrals from the criminal justice system by 8°/o.
• Expanding the use of drug testing on arrest across police forces to target recreational drug users and completing 43,333 tests.
• Establishing 106 Combating Drugs Partnerships across every area in England, overseen by Senior Responsible Owners, to drive local multi-agency delivery. You report notes that the orgnanisers of the festival were not aware of the number of people attending who were under the age of 18 and therefore the number of potentially vulnerable people who could be targeted by drug dealers. All organisers of large events and some medium events, including festivals are required to present to the relevant local authority before an in-principle agreement is given. Festivals will present an Event Safety Management Plan or an Event Management Plan that is reviewed by the local authority as part of the licensing process, and is scrutinised by their SafetyAdvisory Group (SAGs).

Run by local authorities, SAGs are nan-statutory groups of multi-agency representatives formed to give advice and guidance in order to promote best practice and high levels of safety and welfare at events, and ensure events have a minimal adverse impact on the community. All events licence applications must comply with four licensing objectives, which are the prevention of crime and disorder; public safety; the prevention of public nuisance; and the protection of children from harm. Licensing authorities may attach conditions to authorisations. These conditions can be included on a licence at time of grant (e.g. volunteered by the applicant), imposed by the licensing authority as part of an application to vary a licence, or imposed by the licensing authority as part of a licence review. Licence reviews play an important role. Reviews give licensing authorities (and others) powers to address problems, and can be triggered by complaints from local residents or businesses -ensuring appropriate local representation in the decision making processes ­ or by representations from relevant authorities, such as the police or the licensing authority itself. The approval of event licences -including any additional conditions placed on event organisers -is at the discretion of Local Authorities. Policing arrangements around festivals are an operational matter for Chief Constables in consultation with local partners. In line with the Government's approach on tackling drugs, we expect forces to relentlessly attack every phase of the drugs supply chain. If there are concerns about the way police have responded to an incident than individuals can make a Complaint to the forces' professional standards unit or to the Independent Office for Police Conduct (lopc). Your report suggests that further instruction or training for festival staff and volunteers is required `as to the need to be proactive, particularly in view of the prevalence of illicit drugs and teenagers'. The Security Industry Authority (SIA) has statutory responsibility for licensing individuals working in a private security role regulated by the Private Security Industry Act 2001. Regulated roles include `security guarding', where operatives are contracted for the purpose of supplying private security (for example, to venues and festivals), and `door supervisors'. The legislation does not apply to stewards (who perform duties such as directing people to toilets or first-aid facilities), or unpajd volunteers. Neither stewards nor unpaid volunteers require SIA licences, or the associated mandatory qualifications. With respect to licensed security guards and door supervisors, the SIA sets the minimum training required for each role. This includes training on drug awareness, which covers recognising the signs and sy ptoms of drug use and identifying drug dealing. Beyond the minimum standards set by thIoperativestosupplyanyadditional training required for th6 particular situation in-which the regulator, it is for the employer of licensed security licence holder is to be deployed. I would encourage event coordinators to consider any enhanced skills needed for the provision of robust security services and Public Protection during Leeds Festival, and then to communicate those needs with partners (including security contractors and, separately, volunteers and stewards who do not fall within SIA regulation). Your report also asks for clarification on the Government's position on drug testing at festivals also known as Drug Checking Facilities (DCFs). The Government facilitates DCFs provided that the possession and supply of controlled drugs are licensed by the Home Office Drugs and Firearms Licensing Unit or, exceptionally, relevant exemptions under the Misuse of Drugs Regulations 2001 may apply. It has long been a requirement for anyone who wishes to possess, supply or produce controlled drugs to obtain a Home Office controlled drugs licence, including anyone wishing to run a DCF. nrE=^ ~. .-+ r`^+ ^^nA^n^ rlrl i~ . --^ -r`A -h^-.lA ^nlv h^ H^l:`.^r^A `.ih^r.A I;^^r`-^rJ -nrl

operated responsibly in line with Government policy to ensure that they discourage drug use and signpost potential users to treatment and support. The Government recognises the potential harm reduction benefits of back-of-house DCFs at festivals and similar events. Back-of-house DCFs are those which test surrendered or confiscated drugs, but do not return the drugs to the individual or give individualised information on the content of the drugs. Instead, they enable localised public alerts if toxic or extremely dangerous drugs are detected to avoid sending a message that taking any illegal drug can be safe. Organisations wishing to deliver back-of-house DCFs have always been able to apply for a licence and we would encourage them to plan ahead to ensure that there is time to apply for a licence in good time for the festival season next year. In the context of a festival, where DCFs will be aimed predominately at so called recreational users, I expect any DCFs to provide a back-of-house service to provide harm reduction information to users and use`test results to inform wider harm reduction messages or alerts to festival goers and stakeholders but_not provide users with the­ individualised result of the drugs they submit, which would constitute a front-of-house DCF. Given the measures which I have outlined above, I consider that appropriate measures to reduce the risk of deaths like this from happening are in place. I hope that you agree with my assessment, and I would like to thank you for bringing this matter to my attention.

Report sections

Investigation and inquest
On 2 September 2022, I commenced an investigation into the death of David Joseph Celina, aged 16. The investigation concluded at the end of the Inquest on 17 August 2023. The conclusion of the Inquest was a Narrative in which the medical cause of death was 1 a Serotonin Syndrome, 1 b MOMA intoxication. David Celina, aged 16, was sold tablets at the Leeds Festival in August 2022. Shortly after taking tablets, he developed symptoms. Despite prompt treatment, at the festival's field hospital and in a hospital ICU, he could not be revived.
Circumstances of the death
In August 2022, large numbers of people under the age of 18 were permitted to attend the three day outdoor music event known as the Leeds Festival. This admission policy was accepted by the Leeds City Council who licence the festival and had a statutory duty to protect children from harm and prevent crime. The 2022 Crime Plan prepared by West Yorkshire Police acknowledged that the festival was targeted by gangs of criminals who seek to profit by supplying drugs to those attending. It was further acknowledged in this plan that young people under the age of 18 are likely to be na"ive to the risks relating to illicit drugs and hence, vulnerable to exploitation. David J Celina and his 5 friends were in this potentially vulnerable group. They had little experience of illicit drugs. They were attending a music festival for the first time without adult supervision. They were excited, having just received their GCSE results on Thursday 25 August 2022. Their parents did not have sufficient information about the availability of and/or use of drugs at the festival to make an informed assessment of the risk to their sons. David Celina bought three tablets from a drug dealer, represented to be . He had no information concerning the composition of the tablets, their strength, the max dose to take (if such exists), nor the symptoms indicating an adverse reaction which should highlight the need to obtain urgent medical help. He probably took tablets and began to exhibit signs of an adverse reaction within the hour. He walked around the festival site for approximately 90 minutes before collapsing and being taken to the onsite field hospital. The skilled clinicians there realised his condition may prove fatal and so after initial treatment, expedited his transfer to hospital, where he died early the next morninQ.
Copies sent to
2. Local Safeguarding Board the following individuals

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Report details

Reference
2023-0303
Date of report
21 August 2023
Coroner
Kevin McLoughlin
Coroner area
West Yorkshire (Eastern)

Responses identified

Responses identified 5 of 5
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 1 Nov 2023 (estimated).

Sent to

Department for Culture, Media and Sport
Festival Republic
Home Office
Leeds City Council
West Yorkshire Police

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